Provider Demographics
NPI:1083137301
Name:FUENTES, DAVID MICHAEL (ATC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:FUENTES
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 DOE RUN CT
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-3358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19455 DEERFIELD AVE STE 312
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8102
Practice Address - Country:US
Practice Address - Phone:703-729-5010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260027572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer